EPC II Competencies for the Neurologic Exam - I

Organize exam into 1) mental status, speech and language, 2) CNs, 3) motor, 4) sensory, 5) reflex

Cranial Nerves

 CN I: NON-irritating odor 1st with 1 nostril closed  Loss of smell occurs in sinus conditions, trauma, smoking, Parkinson Disease
 CN II & III - Pupillary light response both direct and consensual
o Swinging flashlight test: shine light in one eye, watch for constriction of that pupil.
o Do this again, watch for constriction of opposite pupil. Repeat with other eye. Anisocoria  different pupil size
 CN II - Visual pathway
o Visual fields by confrontation: Stand in front of patient. Have them cover one eye. You close the eye that is opposite their covered
eye. Using both hands, hold up 1 or 2 fingers on each hand pointing inward and bring them from the periphery in until you both
can see them. Ask the patient: “Tell me when you see it, how many fingers total”. Test two quadrants at a time. Repeat to test all 4
quadrants (upper and lower nasal and temporal) for both eyes.
 CN III, IV & VI - Extraocular movements/cardinal movements of gaze – the “H” test. Tip: Make sure your object is at eye level for your patient
o Check for Nystagmus (named for the fast component)
 Nystagmus seen in Cerebellar disease (w/ gait ataxia) and Vestibular Disorders (decreases w/ retinal dixation)
 CN V - Sensation of face and contraction of muscles of mastication
o Sensory: Test sensation as you would light touch – with a wisp from a cotton swab or 2x2 gauze, bilaterally, in all 3 branches of CN V
 Eyes should be closed
 If sensory loss present confirm by testing TEMPERATURE SENSATION
o BLINKING: Corneal Reflex with a cotton swab
o Motor: Have patient bite down while palpating masseter muscle
 Unilateral pontine lesion Bilateral hemispheric disease
 CN VII – Function of facial muscles
o Have patient raise eyebrows, then close eyes tightly as you try to open them back up (gently); have patient smile big and frown
 CN VIII – Test hearing – Know how to do both, but only one test necessary
o Finger rub test: Have patient close eyes; hold hands about 6-8 inches from ears on both sides. Rub fingers together to make a
sound, have patient tell you which side they hear it on. Do at least 3 trials (R-L-R, R-L-L, etc)
o Whisper test (MORE SENSITIVE AND SPECIFIC): Stand about 3 feet behind patient, have them cover one ear and whisper (truly
whisper) a short phrase in the direction of the uncovered ear and have them repeat it back
o Conductive (impaired air thru ear b/c earwax, otosclerosis, and otitis media) or Sensorineural (CN 8 b/c presbyacusis aging)
 CN IX & X - Palate elevation, uvula deviation
o Have patient say “ahhh” – watch for uniformity of elevation of soft palate and deviation of uvula to one side or the other
o Difficulty swallowing  pharyngeal or palatal weakness
 CN XI - Shoulder shrug
o Place your hands on patient’s shoulders. Have them shrug shoulders upwards while you resist
o Turn their head to observe the CONTRALATERAL contraction of SCM
o Supine pt w/ bilateral weakness of SCM  difficulty raising the head of the pillow
 CN XII – Motor function of the tongue
o Have patient stick out their tongue. Move tongue to the right, then to the left.
Muscle Tone
Atrophy results from PNS disorders such as diabetic neuropathy and diseases of the muscles themselves.
Hypertrophy is an increase in bulk with normal or increased strength; increased bulk with diminished strength is called pseudohypertrophy,
seen in the Duchenne form of muscular dystrophy. Corticospinal tract injury can cause mild atrophy due to decreased muscle use.

Motor Strength

 To test motor strength, you resist the action of the muscle in question. For the screening neurologic exam, we are most concerned with the
fact that the nerve reaches the muscle and it makes it contract.
 Shoulder Abduction (axillary nerve - C5, C6)
 Elbow Extension (radial nerve - C6, C7, C8)
 Elbow Flexion (musculocutaneous nerve – C5, C6)
 Wrist Extension (radial nerve - C6, C7, C8)
o Extensor carpi radialis brevis (C5-7)
o Extensor carpi ulnaris (C7-8)
 Wrist Flexion (C6-T1)
o Flexor carpi radialis (C6-7) Flexor carpi ulnaris (C7-T1)
 Finger flexion (C8)
 Abduction of 5th digit (ulnar nerve - C8, T1)
 Hip Flexion (femoral nerve - L2, L3, L4)
 Hip Extension (superior and inferior gluteal nerve - L5-S1, S2)
 Hip Adduction (Obturator nerve - L2, L3, L4)
 Hip Abduction (Superior gluteal nerve - L4, L5, S1)
 Knee Extension (femoral nerve - L2, L3, L4)
 Knee Flexion (Sciatic nerve - L4, L5, S1)
 Dorsiflexion (Fibular nerve - L4, L5)
 Plantarflexion (Tibial nerve - L5, S1, S2)
 Flexion of Great Toe (Tibial nerve - L5, S1, S2)

Extension of Great Toe (Fibular nerve - L5, S1)

Sensory: Light touch –Use the

wisp of a cotton swab or a 2x2
gauze pad. Test each
dermatome. Compare sides.
 C4-T1
 L2-S2

Sensory: Pain - use the open

end of a paper clip, a safety
pin, or a split tongue
depressor. Test each
dermatome. Compare sides.
 C4-T1
 L2-S2

Astereognosis refers to the inability to recognize objects placed in the hand

The inability to recognize numbers, or graphanesthesia, indicates a lesion in the sensory cortex.
Muscle Stretch Reflexes
 Each reflex has two components
o Afferent component – The stimulus required to elicit a response is the threshold. This is a somatosensory neuron function.
o Efferent – The strength of the contraction generated by the stimulus is the amplitude. This is an upper motor neuron function.
 To test muscle stretch reflexes, you strike the tendon insertion of the muscle in question. This creates the “stretch” that activates the reflex
arc which causes the contraction of the muscle. To find the tendon, have the patient contract the muscle in question.
 Biceps (C5) – centrally to medially in the antecubital fossa
 Brachioradialis (C6) – just proximal to the wrist along the lateral border of the radius. Tip: Hold the thumb of the relaxed arm with your
monitoring hand to better sense the reflex.
 Triceps (C7) – on the dorsal surface of the elbow along the distal humerus. Tip: Support the arm held in 90 deg abduction and internal
rotation at the shoulder
 Patellar (L4) – between the patella and the tibial tubercle on the anterior surface of the knee
 Achilles (S1) – proximal to the calcaneus on the posterior/dorsal surface of the ankle. Tip: Slightly dorsiflex the foot with monitoring hand to
better feel the reflex

Hyperactive reflexes (hyperreflexia) are seen in CNS lesions of the descending corticospinal tract. Look for associated upper motor neuron
findings of weakness, spasticity, or a positive Babinski sign.
Hypoactive or absent reflexes (hyporeflexia) occur in lesions of the spinal nerve roots, spinal nerves, plexuses, or peripheral nerves. Look for
associated findings of lower motor unit disease, namely weakness, atrophy, and fasciculations.

Cerebellar Tests
 Finger to Nose: Hold your index finger between you and the patient. Instruct the patient to touch your finger with their index finger, then
touch their nose. Instruct them to touch your finger again after you move it to a new location in front of them. Move your index finger up
and down and across, repeating 4-5 times per side with them touching their nose in between touching your finger. The movements should
be smooth and coordinated. They shouldn’t miss your finger or their nose.
o In cerebellar disease, the heel may overshoot the knee, then oscillate from side to side down the shin. If position sense is
absent, the heel lifts too high and the patient tries to look. With eyes closed, performance is poor.
 Heel to Shin: Have seated patient take heel of one foot and drag it down the anterior tibia of the opposite leg. Switch feet and repeat.
Should be smooth motion.
o In dysmetria the patient’s finger may initially overshoot the mark, but then reach it well. An intention tremor may appear
toward the end of the movement.
 Rapid alternating movements: Have patient place hands on their lap and rapidly lift and flip them front to back 10 to 15 times, one at a time.
Have patient tap foot to your hand quickly
o In cerebellar disease, instead of alternating quickly, these movements are slow, irregular, and clumsy, an abnormality
called dysdiadochokinesis. Upper motor neuron weakness and basal ganglia disease can also impair these movements,
but not in the same manner.
Gait Tests

 Regular gait: Have patient walk 10-15 feet while watching their gait for cadence, favoring one side over the other, overall balance, width of
steps, etc.
 Heel walk: Have patient walk on heels 10-15 feet, then turn around and walk back towards you on their toes.
 Toe walk: see above
 Heel-to-Toe walk TANDEM WALKING: Have patient walk placing heel of one foot directly in front of toes of the other foot in a line for at least
10 steps. Tests balance and coordination
 Tandem walking may reveal Ataxia. Ataxia is seen in cerebellar disease, loss of position sense, and intoxication.
Special tests
 Romberg

o The patient stands with feet in close proximity but not necessarily together, and then is asked to close the eyes.
o The examiner stands nearby to steady if needed. Positive test is patient losing balance.
In ataxia from dorsal column disease and loss of position sense, vision compensates for the sensory loss. The patient stands fairly well with
eyes open but loses balance when they are closed, a positive Romberg sign. In cerebellar ataxia, the patient has difficulty standing with feet
together whether the eyes are open or closed.
 Plantar reflex
o The clinician firmly drags the pointed end of the reflex hammer in a C or backward C motion on the lateral plantar aspect of the foot
going from the heel to the toes and then across the metatarsal heads, but avoiding the arch

The toes should be observed for possible splay and an up going motion at the first MTP joint (a positive test) or the normal down going/curling motion
(a negative test).